Protocol for Completion of the Midwifery Practice Record Book

Transcription

1 Protocol for Completion of the Midwifery Practice Record Book Document reference number Revision number PPPGC- MND-5 Document approved by: Mary Doyle Document developed by Mary Doyle Midwifery Practice Development Coordinator Mary Doyle Date: 07/10/14 Midwifery Practice Development Coordinator Developed Date Reviewed date October 2010 October 2014 Next Review October 2016 Responsibility for implementation Responsibility for evaluation and audit Pages 8 Midwifery Practice development Unit Midwifery Practice Development Unit Page 1 of 8

2 Table of Contents 1.0 Protocol Statement Purpose Scope Definitions Roles and Responsibilities Protocol for Recording, Reviewing and Submitting the Midwifery Practice Record Book Midwifery Student Guidelines The Supervising Midwife or (nurse) Responsibility The CPC Midwifery or Clinical Skills Facilitator Role The Allocation Liaison Officer Role Implementation plan Evaluation and Audit References Appendix Page 2 of 8

3 1.0 Protocol Statement The Midwifery Practice Record Book enables the midwifery student to provide a record of experience to meet the requirements of the EU Directive (2005/36/EC) as set out in An Bord Altranais Standards and Requirements for the Midwife Registration Education Programme (An Bord Altranais, 2005). 2.0 Purpose The purpose of this protocol is to outline the process for the completion and monitoring of the Midwifery Practice Record Book to enable the Midwifery student to progress towards registration as a Midwife with the Nursing and Midwifery Board of Ireland and be awarded a Higher Diploma in Midwifery or BSc Midwifery from the University of Limerick. 3.0 Scope The protocol for completion and monitoring of the Midwifery Practice Record Book applies to all BSc Midwifery and Higher Diploma Midwifery students, registered Midwives and Nurses (neonatal unit), CPC s (Clinical Placement Coordinators) Midwifery, Clinical Skills Facilitator and the ALO (Allocation Liaison Officer Midwifery) and in all maternity placement sites. 4.0 Definitions 4.1 Midwifery Practice Record Book The book a Midwifery student uses to record her clinical experiences as evidence for meeting the EU Requirements and for the Nursing and Midwifery Board of Ireland Midwife Registration Programmes (An Bord Altranais,2005). 4.2 EU Requirements The minimum clinical practice experience required to meet the EU Directive 2005/36/EC and the programme requirements of the University of Limerick in order to be eligible to register as a Midwife with the Nursing and Midwifery Board of Ireland (see ABA, 2005) 4.3 Where Nurse is documented this refers specifically to the experiences gained in the neonatal unit which may be supervised by a registered nurse. 5.0 Roles and Responsibilities 5.1 The Midwifery Practice Development Unit Team will distribute this protocol to practice areas and each midwifery student. 5.2 BSc midwifery and Higher Diploma midwifery students must sign a signature sheet to confirm they have received and agree to adhere to the protocol. 5.3 Midwife managers in all sites to ensure that all midwives are informed of the protocol and their role. 5.4 The Midwifery Practice Development Unit staff will evaluate and review the protocol. Page 3 of 8

4 6.0 Protocol for recording, reviewing and submitting the Midwifery Practice Record Book 6.1 Midwifery Student Guidelines It is the midwifery student s responsibility for the safe keeping, completion and planning of the reviews of the record of experience in the Midwifery Practice Record Book Completion of the Midwifery Practice Record Book The student must have the Midwifery Practice Record Book completed and signed by the supervising midwife (or nurse for neonatal unit entries) by the end of each day in practice. The student is responsible for obtaining the signature and printed name of the supervising midwife/nurse in accordance with recording practice guidelines (ABA, 2002). Record numbers of women and babies will no longer be written in the Midwifery Practice Record Book. When recording clinical information midwifery students will strike through the record number section. Confidentiality and anonymity of women and their families must be maintained at all times when completing the document and all enteries must be recorded in a sensitive manner. Each record must be completed accurately and legibly in the space provided using black ink. Corrective fluid/white stickers must not be used. Records must comply with An Bord Altranais Recording Clinical Practice Guidance to Nurses and Midwives (2002) and other relevant professional and local guidelines. An entry made in error must be bracketed, initialled and have a single line drawn through it so that the original entry is still legible. The correct information should be documented on the next available line. The student must discuss with their preceptor and the CPC Midwifery or Clinical Skills Facilitator if any difficulties arise in meeting the statutory requirements. To forge, alter or misuse any part of the Midwifery Practice Record Book is in breech of the University of Limerick Code of Conduct and the HSE Disciplinary Procedure will be applied accordingly Midwifery Practice Record Book Reviews and Submission The Midwifery Practice Record Book must be available for review at all times. The midwifery student must make an appointment with the CPC Midwifery or Clinical Skills Facilitator to review the Midwifery Practice Record Book at the end of each placement. Page 4 of 8

5 The Midwifery Practice Record Book must be up to date when presented for review. Any entries that are incomplete may not be counted towards meeting the EU requirements. At the following times the student will submit to the University of Limerick the Annual Record of EU Directive 89/594/EEC Minimum Clinical Practice Experience page in the Competency Assessment, Attendance Record and Guidance Document, co-signed by the CPC midwifery/clinical Skills Facilitator: BSc Midwifery - at the end of the academic year Higher Diploma Midwifery - at the completion of each competency level. In order to complete the above the midwifery student must make an appointment with the CPC Midwifery or Clinical Skills Facilitator to formally review the Midwifery Practice Record Book towards the end of the final placement for the academic year (BSc Midwifery) or competency level (Higher Diploma Midwifery). 6.2 The Supervising Midwife (or nurse) Responsibility The supervising registered midwife/nurse, in consultation with the student, facilitates the student to gain the required experience. The supervising registered midwife/nurse reviews the experience gained by the student by the end of each day in practice. When she is satisfied that the student s entry in the Midwifery Practice Record Book is correct she signs and prints her name in the relevant column for each entry. Any difficulty in meeting the statutory requirements must be discussed with the CPC Midwifery or Clinical Skills Facilitator. 6.3 The CPC Midwifery or Clinical Skills Facilitator Role The undertaking of reviews Reviews of the Midwifery Practice Record book are undertaken: Informally according to individual needs At the end of each maternity placement ( end of placement review ) Formally at the end of the final placement for the academic year (BSc Midwifery) or competency level (Higher Diploma Midwifery) The end of the placement review At the end of the placement review any entries that are incomplete or not up to date may not be counted towards meeting the EU requirements. The student will be advised to attain and record further experiences as appropriate. The insertion of additional pages into the Midwifery Practice Record Book is not permitted. If more pages are required consideration should be given to replacing the book. Page 5 of 8

6 The date, reviewers signature and comments for the end of placement review will be recorded on the records review pages towards the end of the Midwifery Practice Record Book. Following the end of placement review the student s record of EU requirements, held in the student s file, is updated The end of year or level review At the end of year or level review the CPC Midwifery/Clinical Skills Facilitator will check the student s completed record of the EU Requirements obtained, in the relevant section of the Competency Assessment, Attendance Record and Guidance Document or in the Higher Diploma midwifery Competency Assessment and Guidance Document for the Midwifery programmes. She/he will co-sign the Annual Record of EU Directive 89/594/EEC Minimum Clinical Practice Experience page with the student prior to the student s submission to the University of Limerick. Any difficulties will be referred to the Midwifery Practice Development Coordinator The completion of the practice placements for the Midwifery Programmes At the end of the programme (BSc midwifery or Higher Diploma midwifery) the CPC Midwifery/Clinical Skills facilitator signs the student off as having completed the EU requirements and forwards the appropriate documentation to the University of Limerick. 6.4 The Allocation Liaison Officer Midwifery Role Reviews EU requirements for individual students to inform placement allocation. 7.0 Implementation Plan All midwifery students will be given the Midwifery Practice Record Book at first year orientation day. All midwifery students will be given a copy of this protocol and will sign to confirm they have read, understand and agree to adhere to the protocol. CPC s Midwifery /Clinical Skills Facilitator to provide update sessions in the practice areas regarding the implementation of the protocol. 8.0 Evaluation and Audit 8.1 An audit of compliance with the protocol will be undertaken in May 2015 (Appendix 1). Timing for future audits will be determined locally. 9.0 References Page 6 of 8

7 An Bord Altranais (2002) Recording Clinical Practice Guidelines to Nurses and Midwives. Dublin. Nursing and Midwifery Board of Ireland. An Bord Altranais (2005) Requirements and Standards for the Midwife Registration Education Programme, Dublin. An Bord Altranais. An Bord Altranais (2007). Requirements and Standards for the Post RGN Midwife Registration Education Programme, Dublin. An Bord Altranais. An Bord Altranais (2010). Practice Standards for Midwives. Dublin. An Bord Altranais. HSE (Health Service Executive) (2007) Disciplinary Procedure for Employees of the Health Service Executive. HSE. University of Limerick Code of Conduct accessed September on/student_academic_administration/student%20handbook% Page 7 of 8

8 Appendix 1: Audit of Midwifery Practice Record Book Please use student number and insert a tick for yes and a x for no. Student Number Criteria Each entry has the name of the supervising midwife/nurse a) printed b) signed Confidentiality and anonymity of women and their families is maintained Each record is completed accurately and legibly in the space provided using black ink. An entry made in error is documented correctly (bracketed, initialled, single line drawn through, original entry legible) End of placement reviews are documented on the review pages A documented review is evident for each placement There are no extra pages Page 8 of 8